EverCare Registered Nurse

Job Summary

The Ever Care Registered Nurse is a core member of the geriatric primary care interdisciplinary team, working in close partnership with the Nurse Practitioner, Medical Assistant, and collaborating physicians to deliver proactive, coordinated, patient-centered care to medically complex older adults. The Ever Care RN owns the chronic care management function of the practice, serving as the primary point of contact for an assigned panel of patients between provider visits.

This role is central to the practice’s success in the Accountable Care Organization (ACO) and other value-based arrangements: the RN delivers and bills Medicare Chronic Care Management (CCM), Principal Care Management (PCM), and related care management services; supports Transitional Care Management (TCM) and Annual Wellness Visits (AWVs); closes quality and care gaps; and works to prevent avoidable emergency department visits, hospitalizations, and readmissions.

Strong clinical assessment, telephonic triage, and therapeutic communication skills are essential, as is the ability to guide goals-of-care and advance care planning conversations with empathy and professionalism.

• Serves as the primary care management nurse for an assigned panel of geriatric patients, maintaining longitudinal relationships with patients, families, and caregivers across care settings.
• Delivers Chronic Care Management (CCM), Complex Chronic Care Management, and Principal Care Management (PCM) services in accordance with Medicare requirements, including obtaining and documenting patient consent, developing and maintaining comprehensive electronic care plans, and accurately tracking and documenting time to support billing of CCM/PCM codes (e.g., CPT 99490, 99439, 99487, 99489, 99424–99427).
• Develops, implements, and continuously updates a comprehensive, patient-centered care plan for each enrolled patient that addresses all chronic conditions, functional status, cognitive status, psychosocial needs, medications, preventive services, and patient/caregiver goals of care.
• Conducts scheduled telephonic and telehealth outreach to enrolled patients between provider encounters to assess symptoms, monitor disease control, reinforce the treatment plan, and identify early signs of clinical deterioration.
• Performs medication reconciliation and adherence assessments at every care management contact and following all transitions of care; identifies polypharmacy risks and potentially inappropriate medications in older adults and escalates findings to the Nurse Practitioner or collaborating physician.
• Supports Transitional Care Management (TCM) by tracking hospital admissions, emergency department visits, and skilled nursing facility stays for the panel; completes interactive contact within two business days of discharge; reconciles discharge medications and ensures timely post-discharge follow-up visits are scheduled to reduce avoidable readmissions.
• Prepares for and supports Annual Wellness Visits (AWVs), including completion of health risk assessments, screenings (cognitive, fall risk, depression, functional status), and preventive care planning in collaboration with the Nurse Practitioner.
• Monitors and works assigned quality measure and care gap reports (e.g., HEDIS, ACO/MSSP quality measures, Medicare Advantage Stars measures); conducts proactive outreach to close care gaps such as immunizations, cancer screenings, diabetic eye exams, and blood pressure control.
• Provides triage for incoming patient and caregiver calls using approved protocols; assesses urgency, initiates appropriate interventions in collaboration with the provider, and works to manage symptoms in place to prevent unnecessary emergency department utilization.
• Provides ongoing education to patients and caregivers on chronic disease self-management, medications, diet, safety, advance care planning, and available community and practice resources.
• Facilitates advance care planning conversations, ensures documentation of advance directives, POST/POLST forms, and patient goals of care in the EMR, and supports timely referral to palliative care or hospice services when appropriate.
• Coordinates referrals, durable medical equipment, home health, behavioral health, and community-based services; acts as a liaison among the patient, specialists, facilities, payers, and community agencies to ensure continuity of care.
• Maintains accurate, timely, and complete documentation in the EMR to support medical necessity, care coordination, quality reporting, risk adjustment data integrity, and compliant billing of care management services.
• Participates in interdisciplinary team (IDT) meetings, daily huddles, and panel review sessions with Nurse Practitioners, physicians, and other team members to review high-risk patients and adjust care plans.
• Uses population health, risk stratification, and utilization data to prioritize outreach to the highest-risk patients on the panel.
• Participates in Quality Assurance and…